F0580

E

Failure to Notify Physician of Ongoing Abdominal Pain and Change in Condition

El Paso, Texas Survey Completed on 03-12-2026

Penalty

Fine: $124,950

Summary

The deficiency involves the facility’s failure to notify a resident’s physician and representative of a significant change in condition and ongoing abdominal pain, as required by facility policy. A cognitively intact resident with a history of diabetes mellitus, hypertension, peripheral vascular disease, coronary artery disease, and a recent left below-knee amputation was admitted from an acute hospital and had active diagnoses including post-procedural pain and phantom pain. The resident’s care plan included monitoring and reporting pain, loss of appetite, refusal to eat, weight loss, and signs and symptoms of infection or adverse reactions to analgesic therapy to the physician. The resident had a PRN order for hydrocodone-acetaminophen 7.5-325 mg every six hours as needed for severe pain, with the diagnosis of phantom pain related to the recent amputation.

On a medical visit, the attending physician documented a new complaint of abdominal pain and diarrhea with low appetite and ordered diagnostic tests, including abdominal ultrasound, KUB, and laboratory work, as well as medications such as Lomotil, Pepto Bismol, Dicyclomine, and PRN ondansetron. Radiology reports for the abdominal ultrasound and KUB indicated no acute process and no bowel obstruction or ileus, and these results were reported to the physician and nurse practitioner. Subsequent 24-hour report sheets and nursing documentation showed that the resident continued to complain of abdominal pain on multiple occasions. On one night, an LVN documented that hydrocodone was given and that the resident continued to complain of abdominal pain, but the DON stated that the LVN did not notify the attending physician or NP of the ongoing abdominal pain.

Further documentation on another date showed that the resident was observed crying, stating that her stomach hurt and that she had not eaten in days, with dry lips noted. The LVN documented that Tylenol was not working, the resident was still in pain, and was refusing to eat, yet the DON reported that the LVN again did not notify the attending physician or NP of the continued abdominal pain. The MAR and administration notes showed multiple administrations of hydrocodone-acetaminophen for high pain levels, including pain scores of 7, 8, and 10, while the 24-hour report sheets continued to reflect that Tylenol was not effective and the resident remained in pain. The facility’s policy on change in a resident’s condition or status required prompt notification of the attending physician and resident representative within 24 hours of a significant change in the resident’s physical or mental condition, but interviews and record review confirmed that the nurses did not contact the physician or NP when the resident’s abdominal pain persisted.

In an interview, the attending physician/medical director stated that he had ordered hydrocodone-acetaminophen specifically for phantom pain related to the recent amputation and that the nurses should have called him to report the resident’s abdominal pain. He indicated he would have given a new order and that he would not have approved the use of hydrocodone for abdominal pain because it could worsen the condition due to constipation. He also noted that the problem included the medication order not being entered into the electronic record with the specific indication of phantom pain related to the lower extremity amputation. The survey findings concluded that the facility failed to consult with the resident’s physician and representative when there was a significant change in the resident’s physical, mental, or psychosocial status, specifically by not notifying the physician when the resident continued to complain of abdominal pain on multiple occasions, contrary to facility policy and the resident’s care plan.

The report also states that this failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. The facility’s own policy required nurses to make detailed observations and gather pertinent information for the provider and to notify the physician within 24 hours of a change in the resident’s medical or mental condition, except in emergencies. Despite this, the documented ongoing abdominal pain, ineffective pain relief with Tylenol, refusal to eat, and high pain scores treated with hydrocodone were not communicated to the physician or NP by the LVNs involved, as confirmed by the DON. This sequence of inactions and omissions in physician notification and consultation formed the basis of the cited deficiency for failure to immediately tell the resident’s doctor and representative of situations affecting the resident.